GP Flashcards
Define domestic abuse
Any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged >/16yrs who are, or have been, intermittent partners or family members regardless of gender or sexuality.
What types of abuse are there?
- psychological
- physical
- sexual
- financial
- emotional
Name 3 ways domestic abuse impacts health?
1) traumatic injuries following assault
2) somatic problems or chronic illness consequent on living with abuse (e.g. headaches, IBS)
3) psychological or psychosocial problems secondary to the abuse (e.g. PTSD, substance misuse)
What tool can be used to assess risk in domestic abuse?
DASH
What are the determinants of health according to the Lalonde Report 1974?
- Genes
- Environment (physical + social + economic environment)
- Lifestyle
- Health care
What is the difference between equity and equality?
Equity is about what is fair and just but equality is concerned with equal shares.
What is horizontal equity?
Equal treatment for equal need (e.g. individuals with pneumonia should all be treated equally)
What is vertical equity?
Unequal treatment for unequal need
e. g. individuals with common cold with pneumonia need unequal treatment
e. g. areas with poorer health may need higher expenditure on health services
What are the dimensions of health equity?
o Spatial (geographical) o Social (age, gender, class-socioeconomic, ethnicity)
What are some wider determinants of health?
e.g. diet, smoking, healthcare seeking behaviour, socioeconomic + physical environment
What are the 3 domains of public health practice?
1) Health improvement
2) Health protection
3) Improving services
What is meant by health improvement?
Concerned with societal interventions aimed at preventing disease, promoting health, and reducing inequalities.
What is meant by health protection?
Concerned with measures to control infectious disease risks and environmental hazards.
What is meant by improving services?
Concerned with the organisation and delivery of safe, high quality services for prevention, treatment and care.
What levels can interventions be delivered at?
- Individual level
- Community level
- Ecological (population) level
What is meant by primary prevention?
Aims to prevent disease before it ever occurs
What is meant by secondary prevention?
Aims to reduce impact of a disease that has already occurred
What is meant by tertiary prevention?
Aim to reduce impact of disease and increase quality of life.
What are the components of a planning cycle?
- needs assessment
- planning
- implementation
- evaluation
What is a health needs assessment?
A systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities.
On what may a health needs assessment be carried out?
- A population or sub-group (e.g. manor practice population)
- A condition (e.g. COPD)
- An intervention (e.g. coronary angioplasty)
What is Bradshaw’s sociological perspective?
Felt need
Expressed need
Normative need
Comparative need
What is felt need?
individual perceptions of variation from normal health
What is expressed need?
individual seeks help to overcome variation in normal health (demand)
What is normative need?
professional defines intervention appropriate for the expressed need
What is comparative need?
comparison between severity, range of interventions and cost
What are 3 approaches to the health needs assessment?
1) Epidemiological
2) Comparative
3) Corporate
What is meant by an epidemiological approach to HNA?
Define problem
Size of problem: incidence/prevalence
Services available: prevention/treatment/care
Evidence base: effectiveness and cost-effectiveness
Models of care: including quality and outcome measures
Existing services: unmet need, services not needed
Recommendations
What are 4 problems with the epidemiological approach?
1) Required data may not be available
2) Variable data quality
3) Evidence base may be inadequate
4) Does not consider felt needs of people affected
What is meant by a comparative approach?
Compares the services received by a population (or subgroup) with others:
Spatial
Social (age, gender, class, ethnicity)
May examine: health status, service provision, service utilisation, health outcomes (mortality, morbidity, QoL, patient satisfaction)
What are 4 problems with the comparative approach?
1) May not yield what the most appropriate level should be (e.g. of provision or utilisation)
2) Data may not be available
3) Data may be of variable quality
4) May be difficult to find a comparable population
What is the meant by the corporate approach?
Receives input from providers, professionals, patients, press, politicians, opinion leaders, commissioners
What are the problems with the corporate approach?
1) May be difficult to distinguish need from demand
2) Groups may have vested interests
3) May be influenced by political agendas
4) Dominant personalities may have undue influence
Give one health related example of something that you consider is demanded but not needed or supplied, clearly explaining the reasoning for your example.
Medical marijuana
- large demand from some areas of the population
- there is no supply as in unavailable on NHS
- NICE say it is not needed as there are other therapies available
What is an asylum seeker?
A person who has made an application for refugee status
What is a refugee?
A person granted asylum and refugee status
What is indefinite leave to remain?
When a person is granted full refugee status and given permanent residence in the UK
What is an unaccompanied asylum-seeking child?
- someone who has crossed an international border in search of safety
- is applying for asylum in his/her own right
- is under the age of 18
- is without family members or guardians
What are barriers to accessing health care for asylum seekers?
- lack of knowledge of where to get help
- lack of understanding of how NHS works
- language/communication barriers
- dispersal by home office
- not homogenous group
What are the 3 core principles of the NHS?
1) That it meets the need of everyone
2) That it will be free at the point of delivery
3) That it is based on clinical need, not ability to pay
What is the inverse care law?
The principle that the availability of good medical or social care tends to vary inversely with the need of the population served. (Julian Tudor Hart in 1971.)
What are health inequalities?
The preventable, unfair and unjust differences in health status between groups, populations or individuals that arise from the unequal distribution of social, environmental and economic conditions within societies, which determine the risk of people getting ill, their ability to prevent sickness, or the opportunities to take action and access treatment when ill-health occurs.
What are vulnerable groups?
Homeless, gypsies and travellers, asylum seekers, LGBTQ, LD, MH problems, ex-prisoners and care leavers.
What are causes of homelessness?
viction by private landlords Relationship breakdown Domestic abuse Disputes with parents Poverty Housing supply + affordability Unemployment or insecure employment
What are the barriers to accessing healthcare for the homeless?
Difficulties with access to health care
- Due to opening times, appointment procedures, location + perceived/actual discrimination
Lack of integration between mainstream primary care services and other agencies
- Housing, social services, criminal justice system and voluntary sector
Other things on their mind
- Health isn’t prioritised when there are more immediate survival issues
May not know where to find help
What are the layers of Maslow’s hierarchy of needs?
- physiological
- safety
- love/belonging
- esteem
- self-actualisation
Give examples of physiological needs in Maslow’s hierarchy?
Breathing, food, water, sex, sleep, homeostasis, excretion
Give examples of safety needs in Maslow’s hierarchy?
Security of:
- body
- employment
- resources
- morality
- the family
- health
- property
What are the barriers to accessing health care for gypsies and travellers?
o Reluctance of GPs to register them and for GPs to visit sites o Poor reading and writing skills o Communication difficulties o Frequent movement/transient sites o Mistrust of professionals
Barriers to accessing healthcare for LGBT?
- Stigma/prejudice
- Fear/discomfort of disclosing LGBT status due to real/perceived homophobia
- Previous negative experiences
What is human trafficking
the movement of people by means such as force, fraud, coercion, or deception with the aim of exploiting them
types of exploitation
- sexual
- force labour
- domestic services
- forced criminality
- organ harvesting
barriers to accessing healthcare for modern slaves
- no fixed address
- lack official documents
- language barriers
- unaware of entitlement to care
- controlled movement by trafficker
- stockholm syndrome
What is health psychology?
Emphasises the role of psychological factors in the cause, progression and consequences of health and illness. It aims to put theory into practice by promoting healthy behaviours and preventing illness.
What are the 3 main health behaviours?
Health behaviour
Illness behaviour
Sick role behaviour
What is health behaviour?
Aimed to prevent disease (e.g. eating healthily)
What is illness behaviour?
Aimed to seek remedy (e.g. going to the doctor)
What is sick role behaviour?
Any activity aimed at getting well (e.g. taking prescribed medications; resting)
Give example of health damaging/impairing behaviour?
Smoking, alcohol + substance abuse, risky sexual behaviour, sun exposure, driving without a seatbelt.
Give example of health promoting behaviour?
Taking exercise, healthy eating, attending health checks, medication compliance, vaccinations.
What are some non-modifiable risk factors for cancer?
age, gender, genetics, ethnicity
what are some modifiable risk factors for cancer?
smoking, diet, alcohol
What are some health promotion techniques?
Campaigns:
- ‘everyone enjoys a drink, no one enjoys a drunk’
- Change4Life Campaign, ‘5 a day’
- Stoptober, Movember
Screening + immunisations:
- cervical smear screening
- MMR vaccine
What is unrealistic optimism?
Individuals continue to practice health damaging behaviour due to inaccurate perceptions of risk and susceptibility.
What are perceptions of risk influenced by?
1) Lack of personal experience with problem
2) Belief that preventable by personal action
3) Belief that if not happened by now, it’s not likely to
4) Belief that problem infrequent
What is Davison 1990 find about patient’s perception of risk?
patients had their own ideas about cause and perception of risk
What did Everette 2014 find about patient’s perception of risk?
Lower risk perception was associated with reduced attendance for cardiac rehabilitation and reduced adherence to their medication regimen.
What factors effect patient compliance?
- SE of medication
- polypharmacy
- language barriers
- poverty
- failure to understand
- lack of belief
What are the NICE guidelines on behaviour change?
1) Planning interventions
2) Assessing the social context
3) Education and training
4) Individual level interventions
5) Community level interventions
6) Population level interventions
7) Evaluating effectiveness
8) Assessing cost-effectiveness
What is NCSCT?
National Centre of Smoking Cessation + Training.
A social enterprise to support the delivery of effective evidence-based tobacco control programmes and smoking cessation interventions provided by local stop smoking services.
The NCSCT:
• Delivers training and assessment programmes
• Provides support services for local and national providers
• Conducts research into behavioural support for smoking cessation
What is the health belief model by Becker 1974?
Individuals will change if they:
- Perceived susceptibility: Believe they are susceptible to the condition in question (e.g. heart disease)
- Perceived severity: Believe that it has serious consequences
- Perceived benefits: Believe that taking action reduces susceptibility
- Perceived barriers: Believes that the benefits of taking action outweigh the costs
What are cues to action in health belief model?
- Unique component of the model
- Can be internal or external cues
- Smoking cessation: Stead et al 2008 – even brief simple advice from a GP can make a patient stop smoking for up to 12 months
- Not always necessary for behaviour change
What are the critiques of health belief model?
- Alternative factors may predict health behaviour, such as outcome expectancy (whether the person feels they will be healthier as a result of their behaviour) and self-efficacy (the persons belief in their ability to carry out preventative behaviour)
- As a cognitively based model, HBM doesn’t consider the influence of emotions on behaviour
- HBM doesn’t differentiate between first time and repeat behaviour
- Cues to action are often missing in HBM research
What is the most important factor for addressing behaviour change in patients according to health belief model?
Perceived barriers
What is theory of planned behaviour - Ajzen 1988?
Proposed the best predictor of behaviour is ‘intention’ e.g. ‘I intend to give up on smoking’
What is intention determined by?
- attitude
- subjective norm
- perceived behaviour control
Give an example of theory of planned behaviour?
- Attitude: I do not think smoking is a good thing
- Subjective norm: most people I know want me to give up smoking
- Perceived behaviour control: I believe I have the ability to give up
- Behaviour intention: I intend to give up smoking
How do you help people act on their intentions?
Perceived control Anticipated regret Preparatory actions Implementation intentions Relevance to self
What are some critiques of theory of planned behaviour?
- Criticisms include lack of temporal element, and the lack of direction or causality
- TPB is a “rational choice model”, it doesn’t take into account emotions such as fear, threat, positive effect, all of which may disrupt rational decision making
- Model does not explain how attitudes, intentions and perceived behavioural control interact
- Habits and routines – procedural rationality - bypass cognitive deliberation and undermine a key assumption of the model
- Assumes that attitudes, subjective norms and PBC can be measured
- Relies of self-reported behaviour
What are the stage models of health behaviour?
Stage theories see individuals located at discrete ordered stages, rather than on a continuum
Each stage denotes a greater inclination to change outcome, typically behaviour, than the previous one.
Give an example of a stage model of health behaviour?
Transtheoretical model
aka stages of change model
What are the stages in the transtheoretical model?
1) pre-contemplation
2) contemplation
3) preparation
4) action
5) maintenance
6) relapse
Advantages of transtheoretical model?
- Acknowledges individual stages of readiness
- Accounts for relapse
- Temporal element
Critiques of transtheoretical model?
- Not all people move through every stage, some people move backwards and forwards or miss some stages out completely
- Change might operate on a continuum rather than in discrete stages
- Doesn’t take into account: values, habits, culture, social and economic factors
What is motivational interviewing?
A counselling approach for initiating behaviour change by resolving ambivalence
What is nudge theory?
‘Nudge’ the environment to make the best option the easiest – e.g. fruit next to checkouts, opt-out pensions
What are some transition points in life for making change?
o Leaving school o Entering workforce o Becoming parent o Becoming unemployed o Retirement and bereavement
Define meta-analysis?
A statistical analysis that combines the results of multiple studies.
Define evaluation of health services?
- Evaluation is the assessment of whether a service achieves its objectives
What can be evaluated in health services?
- SIngle intervention eg. drug effectiveness
- Public health interventions
- HEalth economic evaluation
- Health technology assessment
What is the framework for health service evaluation?
Structure
Process
(Output)
Outcome
What is meant by structure?
What is there:
- buildings, staff, equipment
- e.g. no. of ICU beds per 1000 population, number of vasc surgeons per 1000 population
What is meant by process?
What is done:
No. of patients seen in A&E
The process through which patients go in A&E
Number of operations performed
What is meant by outcome?
o Classifation of health outcomes
1. Mortality
2. Morbidity
3. Quality of life/PROMs (patient reported outcome measures)
4. Patient satisfaction
o Or 5 D’s: Death, disease, disability, discomfort, dissatisfaction.
Issues with health outcomes?
- Link (Cause and effect) between health service provided and health outcome may be difficult to establish as many other actors may be involved
o e.g. case-mix, severity, other confounding factors - Time lag between service provided and outcome may be long
o E.g. between healthy eating intervention in childhood and incidence of T2DM in middle age - Large sample sizes may be needed to detect statistically significant effects
- Data may not be available
- May be issues with data quality
o CART – Completeness, Accuracy, Relevance, Timeliness
What are Maxwell’s Dimensions of Quality?
(3E’s and 3A’s)
o Effectiveness
Does the intervention / service produce the desired effect?
o Efficiency
Is the output maximised for a given input (or is the input minimised for a given level of output)?
o Equity
Are patients being treated fairly?
o Acceptability
How acceptable is the service offered to the people needing it?
o Accessibility
Is the service provided? Geographical access; Costs for patients; Information available; Waiting times
o Appropriateness
Is the right treatment being given to the right people at the right time? [Overuse? Underuse? Misuse?]
What are the different evaluation methods?
Qualitative methods:
- consult relevant stakeholders as appropriate
o e.g. staff, patients, relatives and carers, policy makers, commissioners
- Qualitative methodology:
o Observation:
Participant and non-participant observation
o Interviews
o Focus groups
o Review of documents
Quantitative methods - Routinely collected data o E.g. hospital admissions, mortality - Review of records o Medical administrative - Surveys - Other special studies o E.g. using epidemiological methods
What factors contribute to promotion of excessive energy intake?
o Genetics o Employment (shift work) o Early developmental factors o TV viewing/advertisements o Characteristics of food (energy density, satiety and satiation, portion size) o Reduced physical activity o Sleep o Environmental cues o Psychological factors
What is malnutrition?
- Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients.
Two groups of malnutrition?
o Undernutrition: Which includes stunting (low height for age), wasting (low weight for height), underweight (low weight for age) and micronutrient deficiencies.
o Overweight: Obesity and diet-related noncommunicable diseases (heart disease, stroke, diabetes, cancer)
Chronic medical conditons requiring nutritional support?
Cancer CF Coeliac disease Diabetes FtT
Early influences on feeding behaviour?
- Maternal diet and taste preference development
- Role of breastfeeding for taste preference and bodyweight regulation
- Parenting practices
- Other important influences:
o Age of introduction of solid food
o Types of food exposed to during weaning period
What is early flavour exposure?
- Taste and olfactory systems are capable of detecting flavour info prior to birth
- Like other mammals, human foetuses swallow a significant amount of amniotic fluid during gestation, by the final trimester (one litre per day)
- Amniotic fluid and human milk transmit volatiles (alcohol, ketones, acids) from the maternal diet
Composition of breastmilk:
- Colostrum – fat, protein, protective factors, 3 days after birth
- Foremilk – beginning of a feed (watery)
- Hindmilk – end of a feed, energy dense.
Characterisitcs of Non-organic feeding disorders?
• High prevalence in children younger than 6 years old
• Characterized by feeding aversion, food refusal, food selectivity, fussy eaters,
failure to advance to age-appropriate foods, negative mealtime interactions
• Parents of children with NOFEDs often use maladaptive parental feeding
practices (Romano et al. 2015)
What are the 3 eating disorders?
Anorexia nervosa, Bulimia nervosa, binge eating disorder
Risk factors for eating disorders?
o Type A personality o Low self esteem o Family history o Perfectionism o Behavioural inflexibility o Bullying about weight
What is an eating disorder?
“clinically meaningful behavioural or psychological pattern having to do with eating or weight that is associated with distress, disability, or with substantially increased risk of morbidity or mortality”
3 basic forms of dieting?
1) Restrict the total amount of food eaten
2) Do not eat certain types of food
3) Avoid eating for long periods of time
Issues with dieting?
The problem with dieting:
i) Risk factor for the development of eating disorders
ii) Dieting results in a loss of lean body mass, not just fat mass
iii) Dieting slows metabolic rate and energy expenditure
iv) Chronic dieting may disrupt ‘normal’ appetite responses and increase subjective sensations of hunger
What is the pattern of weight loss?
Long term weight loss is challenging – interventions typically demonstrate weight loss, plateau then weight regain. Weight cycling often leads to ‘overshoot’ and may accelerate weight gain. Non obese dieters are at increased risk of fat overshooting compared to obese dieters.
Why is dieting difficult for some?
Those susceptible to obesity (and who try to diet) appear particularly:
i) Unresponsive to internal cues that signal satiety (when overconsuming) and hunger (when dieting)
ii) Vulnerable to external cues that signal availability of palatable food
What is the externality theory of obesity?
Externality theory of obesity Normal weight individuals responsive to internal homeostatic cues. Overweight individuals eat according to: • External cues • No compensation after preload • Time of day • Offer lurid descriptions of desserts • Sensory food cues This theory is too general however, not all obese are external and not all lean is internal.
What is restrained eating?
the deliberate attempt to inhibit food intake in order to maintain or to lose weight.
What is the restraint theory?
Restrained eaters:
- Larger range between hunger and satiety levels, so takes them longr to feel hungry and requires more food to satisfy them..
Normal eater:
- Food consumption is regulated by biological processes to keep food intake within a set range
- Hunger keeps intake of food above a specific minimum level
- Satiety keeps food below a maximum level
Critique of restraint theory?
- Restraint theory suggests a link between food restriction and overeating
- Dieters, bulimics and anorexics report episodes of overeating
- Cannot explain restriciting behaviour in anorexics (ie. Avoiding meals, portioning meals) as according to restraint theory, this should result in overeating and weight gain, not weight loss
What is the boundary model?
- Unrestrained eaters are intuitive and regulate food intake without conscious effort
- Restrained eaters rely on consciously controlled processes to regulate food intake
- Break down of dietary restraint leads to “what-the-hell” cognitions
Disinhibitors: o High energy preloads or mereky velief of high energy preload o Large portion size and/or alcohol o Cognitvie load: stress o Strong emotion
What is Goal Conflict theory?
•Chronic dieters experience conflict between 2 incompatible goals:
- Eating enjoyment and weight control
- Individuals are motivated to pursue a weight loss goal, however, pervasive food cues in the environment prime the goal of food enjoyment “external eating” – inhibition of weight loss goal
- Successful dieters (minority of restrained eaters), use food cues in the environment as a weight loss motivational goal
What is the portion size effect?
consumption of large portion sizes of energy dense food facilitates over-consumption
What is a population approach to prevention?
The population approach is a preventative measure delivered on a population wide basis and seeks to shift the risk factor distribution curve
e.g. dietary salt reduction through legislation, working with the food industry and advice to the general public should shift the blood pressure distribution curve to the left.
What is the high-risk approach to prevention?
The high-risk approach seeks to identify individuals above a chosen cut-off and treat them
e.g. screening for people with high BP and treating them
What is the prevention paradox?
A preventive measure which brings much benefit to the population often offers little to each participating individual.
- “If all male British doctors wore their car seat belts on every journey throughout their working lives, then for one life thereby saved there would be about 400 who always take that preventive precaution.
-“399 would have worn a seat belt every day for 40 years without benefit to their survival.”
Association + causation?
Bias: e.g. studies finding associations were more likely to have been published, resulting in publication bias
Chance: significant associations could have arisen by chance
Confounding: e.g. coffee drinkers would have had a healthier diet and lifestyle which would have reduced their CVD risk
Reverse causality: e.g. people who are already ill don’t drink coffee.
What is disability?
Related to anyone who has a physical, sensory or mental impairment which seriously affects their daily activities.
What can visual impairment people see?
- A very small percentage of blind people see nothing at all.
- Some blind people can differentiate between light and dark
- Some have no peripheral vision..
- Some have no central vision,
- Some see patchwork of blanks and defined areas.
- Some may see enough to read text, although they may have difficulty crossing roads.
What are common eye conditions that can make people blind?
ARMD RP Glaucoma Diabetic retinopathy Charles Bonnet Syndrome
How do you define addiction?
Craving
Tolerance
Compulsive drug-seeking behaviour
Physiological withdrawal state
Describe heroin
Action at opiate receptors
Units: £10 a bag, gram, 16th oz ‘teenth’
Must be used approx. 8 hourly
Routes of administration (powder): smoking/chasing, snorting, oral IV SC, IM, rectal
Effects: euphoria, intense relaxation, miosis, drowsiness
Adverse effects: dependence + withdrawal sx, nausea, itching, sweating, constipation (general, IV use), overdose
Describe cocaine/crack
- Blocks reuptake of mood enhancing neurotransmitters at the synapse (serotonin, dopamine)
- Intense pleasurable sensation
- Reinforcement leading to further use
- Depletion at secretory neurone
- Anxiety, panic, adrenaline secretion, ‘wired’
Effects:
- confidence, well-being, euphoria, impulsivity, increased energy, alertness
- impaired judgment, decreased need for sleep
– may produce anxiety, HT, arrhythmias
– subsequent “crash”-dysphoria
– chronic effects-depression, panic, paranoia, psychosis, damaged nasal septum, CVA, respiratory problems
How are drug addictions treated?
- harm reduction (esp for non-opiate users)
- detoxification (lofexidine, buprenorphine)
- maintenance: methadone (full agonist), buprenorphine (partial agonist/antagonist)
- relapse prevention (naltrexone)
- psychological interventions
- alternative therapies
- referral for allied problems (Hep C, STDs etc)
What can be used in a quick detoxification?
Buprenorphine
What can be used in relapse prevention?
Naltrexone tablets
Avoid benzodiazepines
What are government national guidelines for alcohol intake?
14 units/week for women
14 units/week for men
- Pregnant women advised to abstain altogether for 1st trimester and then no more than 2 units per week
What is hazardous drinking?
Pattern of alcohol use which increases someone’s risk of harm.
Higher risk drinking: 50+ units (men), 35+ units (women)
Increasing risk drinking: 22-50 units (men), 15-35 units (women)
What is a unit?
Standard measure of the alcohol content of a drink, taking into account the strength (%ABV) and the volume (pints/litres) this is 8g of alcohol.
How do you calculate units?
The % ABV relates to the number of units in a litre of drink
E.g. in a litre of 12% strength wine = 12 units, a litre of whiskey 40% = 40 units etc
Why do men metabolise alcohol faster?
due to % body fat
Why are women drinking now more than ever?
- More socially acceptable
- More disposable income
- More drinks marketed at women
- More drinking places aimed at women customers
What’s the link between deprivation and alcohol?
- Interaction between alcohol and social class complex
- Adverse effects of alcohol exacerbated amongst lower socio-economic groups
- More likely to experience negative effects directly and indirectly
- Lack of money means less likely to protect themselves against negative health and social consequences
What are some social + psychological risk factors for problem drinking?
- Drinking within the family
- Childhood problem behaviour relating to impulse control
- Early use of alcohol nicotine and drugs
- Poor coping responses to life events
- Depression as a cause not a result of problem drinking
What are the most common causes of death due to alcohol?
Accidents and violence
Malignancies
Cerebrovascular disease
Coronary heart disease
Potential interventions for alcohol problems?
- Good evidence for increasing price and reducing supply by governments, not politically popular though
- Also good evidence for screening and brief intervention from health care workers
- NHS confed Jan 2010 call for more joined up services, eg in A&E departments
- June 2010 NICE guidance for commisioners and clinicians
Screening tests for alcohol?
AUDIT
CAGE
What is alcohol dependence syndrome?
Cluster of 3 of below Sx in a 12-month period
• tolerance-increasing amount of alcohol to achieve the same effect
• characteristic physiological withdrawal
• difficulty controlling onset, amount and termination of use
• neglect of social and other areas of life
• spending more time obtaining and using alcohol
• continued use despite negative physical and psychological effects
What are some problems assoc with long-term use of alcohol?
Wernicke Encephalopathy: vitamin b1 deficiency on withdrawal of alcohol
o Triad Sx: acute mental confusion, ataxia, opthalmoplegia
o Tx: IV/IM/oral B1 (pabrinex), reversible
o Not treating can lead to Korsakoff’s
Korsakoff’s syndrome: amnestic disorder due to enduring B1 manutrition, not reversible
o Sx: memory loss (esp short term), loss of spontaneity, initative + confabulation
o Ix: CT scan
Delirium tremens: short lived toxic confusional state as a result of reduced alcohol intact in alcohol dependence individuals.
o Clouding of consciousness/confusion/seiures
o Hallucinations
o Tremor
o Tx: supportive fluids, benzodiazepine (prevent fitting)
What is the treatment for HTN?
First line
- If <55yrs: Ace-i or ARB
- If >55yrs: CCB
Second line
- add the other
Third line
- add thiazide-like diuretic
Give an example of an Ace-i
Ramipril
Lisinopril
Give an example of an ARB
Candesartan
Losartan
Give an example of a CCB
Amlodipine
Nifedipine
Give an example of a thiazide-like diuretic?
Indapamide
Bendroflumethiazide
First line treatment for heart failure?
Ace-i (use ARB if Ace-i intolerable )
Beta-blocker
Loop diuretics or spironolactone
Give example of primary, secondary and tertiary prevention for Coronary heart disease?
Primary: stop smoking, exercise, diet, reduce alcohol intake
Secondary: statins, aspirin, Qrisk
Tertiary: PCI, CABG
Describe population approach to prevention?
Action targeted at whole population to reduce risk (e.g. sugar tax)
Describe high-risk approach?
Action targeted at high risk individuals (e.g. give statins to patients with cholesterol above a certain level)
List some notifiable diseases
1) measles
2) mumps
3) rubella
4) malaria
5) whooping cough
Who do you report notifiable diseases to?
To notify proper officer at local council or health protection team
Traffic light system
Colour?
Green: normal colour
Amber: pallor reported by parents/carer
Red: pale/mottled/ash+blue
Traffic light system
Activity?
Green: responds normally to social cues, content/smiles, stays awake and strong, normal cry OR not crying
Amber: not responding normally to social cues, no smile, decreased activity, wakes only with prolonged stimulation
Red: no response to social cues, appears ill to doctor, does not stay awake if roused, weak, high-pitched or continuous cry.
Traffic light system
Respiratory?
Green: nothing there
Amber: nasal flaring, >50 RR (6-12months), >40 RR (>12months), O2 sats <95%, crackles in chest
Red: grunting, tachypnoea >60, moderate or severe chest indrawing
Traffic light system
Circulation + hydration?
Green: normal skin + eyes, moist mucous membrane
Amber: tachycardia >160bpm (<12months), >150 (12-24months), >140 (2-5yrs)
- CRT >3secs
- dry mucous membranes
- poor feeding
- reduced urine output
Red: reduced skin turgor
Traffic light system
Other?
Green: none of amber or red sx
Amber: aged 3-6 months with temp >39 degrees, fever >5 days, rigors, swelling of limb or joint, non-weight bearing
Red: aged <3 temp >38 degrees, non-blanching rash, bulging fontanelle, neck stiffness, status epilepticus, focal seizures
What is the fever pain score?
5 item scoring system that enables effective Abx prescribing. It is used for sore throat.
What 5 things are taken into account on the fever pain score?
1) Fever during previous 24hrs
2) Purulence
3) Attend rapidly (<3days)
4) Inflamed tonsils
5) No cough/coryza
(FPAIN)
- greater score = greater bacterial infection chance
What do you do with score of 0-1 on fever pain score?
13-18% chance of streptococci
- use no Abx strategy
What do you do with score of 2-3 on fever pain score?
34-40% chance of streptococci
- use delayed prescription strategy
What do you do with score of >4 on fever pain score?
62-65% chance of streptococci
- use immediate Abx if severe or 48hr short back-up prescription
What Abx is used for strep throat?
Phenoxymethylpenicillin
OR
Clarithromycin (if penicillin allergy)
Describe normal vaginal discharge?
- white or clear
- non-offensive
- varies with menstrual cycle
> thick and sticky for most of cycle
> becomes clearer, wetter and stretchy around ovulation - varies during pregnancy, contraceptive use and sexual stimulation (heavier)
- varies at menopause (decrease in volume)
Describe abnormal vaginal discharge?
- changes in consistency
- yellow, green or grey
- resemble cottage cheese in colour or consistency
- foamy or frothy
- strong smell of fish, yeast or other odour
- is brown or blood-stained
Assoc with itch, soreness, dysuria, pelvic pain + bleeding.
Describe discharge in bacterial vaginosis?
- white/grey
- thin
- fishy odour
- no usual soreness or itchiness
Describe discharge in vaginal candidiasis (Thrush)?
- white
- cheese-like
- non-malodorous
- assoc with itching + soreness
Describe trichomoniasis discharge?
- frothy
- yellow/green
- varies from thin to thick
What is Gillick competence?
A child’s ability to consent to medical treatment.
What is the Gillick test?
- consent is only valid if given voluntarily
- no pressure should be put on pt
- competence should be tested for each decision
- if pt fails gillick test, parents or court can make decision
What are the Fraser guidelines?
Relate only to contraception and sexual health. 5 criteria:
1) pt has sufficient maturity and intelligence to understand the nature and implications of the proposed treatment
2) pt cannot be persuaded to tell parents or to allow the doctors to tell them
3) pt is very likely to begin or continue having sexual intercourse with or without contraceptive treatment
4) pt’s health is likely to suffer unless he/she receives advice or treatment
5) advice or treatment is in the young person’s best interest
Tools used for dementia screening?
- MMSE
- 6-CIT (6 cognitive impairment test)
- AMT (abbreviated mental test)
What is a COP3 form?
An assessment of capacity as part of an application to make decisions about them.
What is an IMCA?
Independent Mental Capacity Advocate
- they represent patients without capacity
What screening tool is used to detect depression?
PHQ-9
What screening tool is used to detect anxiety?
GAD-7
Risk factors for TB?
- overcrowded
- immunocompromised
- IVDU
- asian
- homeless
- elderly
